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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br /> 5/2011 (303)866-3581 Fax(303)866-3589 htip://www.water.state.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells,monitoring and other holes. Type or <br /> print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br /> Well Permit Number of the well being plugged or <br /> MH File Number MH- Hole ID#/Name <br /> Individual/Comoanv rlesaonsiibble for plugging and sealing the well: <br /> NAME(S) lu <br /> Mailing Address Cell-Lf V- bL U'2 <br /> City,St.,Zip 1 <br /> Phone Js oot S <br /> Well(Hole)Owner: <br /> c"t{ 11 `` ��"" <br /> NAME(S) cola d 00 Ij;--e w , Phone <br /> Mailing Address,City,St.,Zip "P J�nk T�Q Sdtii iA C-0 _�� <br /> ACTUAL WELL LOCATION: County S'A utu" <br /> Property Address,City,St,Zip <br /> 1/4 of the_1/4,Sec._,Twp. ❑ N.or❑S., Range E.or❑W.,_P.M. <br /> Distance from Section Lines Ft.From ❑ N.or❑ S., Ft. From❑E.or❑ W.Line. <br /> Subdivision Name Lot ,Block ,Filing/Unit <br /> Optional:GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br /> Format must be UTM, zone 12 ❑ or zone 13K* Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Fasting n7�k?,O , 4 Northing <br /> I(we)report the existing well(hole)was plugged and sealed on the date of 7 for the following reason(s): <br /> ❑ The well was plugged and sealed as required under Well Permit Number <br /> ❑The well was not in use and was plugged and sealed. <br /> Other(please explain) 4r-) S le C LU <br /> I <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Method of Placement Interval <br /> t ,` cf Pti/ au uj 1 from 7 , feet to feet <br /> from 5 feet to�_feet <br /> K tA�wt( t1 from y feet to t,_feet <br /> wtu S uw '' <br /> Intervals of casing removed/ripped in feet from feet to feet <br /> Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. <br /> (we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> _ � I <br /> Signature( Plea a print the Signer's Name&Title Date <br /> 'D JJ1W PIE <br /> It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is responsible for notifying the owner of this requirement. <br />